A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study

Üzeyir Kalkan, Kadir Bakay, Üzeyir Kalkan, Kadir Bakay

Abstract

Background: The aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH).

Methods: This two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed.

Results: Seventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (55.5 vs. 59 min, respectively; p = 0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range 6-12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range 1-4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p = 0.456). The mean uterine weight for the ST group and MT group was comparable (258.6 ± 88.6 g vs. 232.9 ± 102.5 g, respectively; p = 0.107). The preoperative vaginal length was not significantly different between the groups (p = 0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p = 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range 1-5) in both groups (p = 0.636). The complication rates were similar between the groups (p = 0.230).

Conclusion: The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support.

Keywords: Apical prolapse; Colpotomy; Hysterectomy; Laparoscopic surgery; Suture technique.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
The steps of the modified Bakay technique are described. First suture is placed on the right USL (A) then helically proceeded for suspension/plication (B). The suture continued circumferentially in the counterclockwise direction on the line between the cervicovaginal junction and the bladder (C–E) in a full-thickness purse string fashion. This suture symmetrically ended in the left USL, across the point of the start (F–H). Colpotomy is performed circumferentially using laparoscopic cold scissors and/or knife (I), maintaining a safe distance from the suture line, paying attention not to cut the suture. The detached uterus is removed vaginally (J) and both ends of the prior suture line are knotted securely (K, L)
Fig. 2
Fig. 2
The CONSORT study flow chart

References

    1. AAGL Advancing Minimally Invasive Gynecology Worldwide AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18(1):1–3. doi: 10.1016/j.jmig.2010.10.001.
    1. Englund M, Robson S. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. J Minim Invasive Gynecol. 2007;14(6):724–728. doi: 10.1016/j.jmig.2007.07.007.
    1. Hwang JH, Lee JK, Lee NW, Lee KW. Vaginal cuff closure: a comparison between the vaginal route and laparoscopic suture in patients undergoing total laparoscopic hysterectomy. Gynecol Obstet Investig. 2011;71:163–169. doi: 10.1159/000316052.
    1. Smith K, Caceres A. Vaginal cuff closure in minimally invasive hysterectomy: a review of training, techniques, and materials. Cureus. 2017;9:1–17.
    1. Mühlfay G, Horváth KU, Mocan SL, Budu VA, Ilyes IA, Doroş CI, et al. A study on the type of lesions achieved by three electrosurgical methods and their way of healing. Rom J Morphol Embryol. 2015;56(4):1383–1388.
    1. DeLancey J. Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol. 1993;36:897–909. doi: 10.1097/00003081-199312000-00015.
    1. Lowder JL, Meister M, Ghetti C, Li W, Winger DG, Shepherd JP. Reestablishing apical support at time of hysterectomy not performed for prolapse. American Urogynecologic Society Pelvic Floor Disorder Week 2015. Seattle: Female Pelv Med and Reconstr Surg; 2015.
    1. Kantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. Int Urogynecol J. 2015;26:207–212. doi: 10.1007/s00192-014-2474-y.
    1. Eilber KS, Alperin M, Khan A, Wu N, Pashos CL, Clemens JQ, Anger JT. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol. 2013;122:981–987. doi: 10.1097/AOG.0b013e3182a8a5e4.
    1. Ross WT, Meister MR, Shepherd JP, Olsen MA, Lowder JL. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol. 2017;217(4):436.e1–436.e8. doi: 10.1016/j.ajog.2017.07.010.
    1. AAGL AAGL practice report: practice guidelines on the prevention of apical prolapse at the time of benign hysterectomy. J Minim Invasive Gynecol. 2014;21:715–722. doi: 10.1016/j.jmig.2014.04.001.
    1. Hill AM, Davis KM, Clark-Donat L, Hammons LM, Azodi M, Silasi DA. The effect of vertical versus horizontal vaginal cuff closure on vaginal length after laparoscopic hysterectomy. J Minim Invasive Gynecol. 2017;24:108–113. doi: 10.1016/j.jmig.2016.09.015.
    1. Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol. 2012;206(4):284–288. doi: 10.1016/j.ajog.2011.08.026.
    1. Bakay K. Introduction of a novel modification in laparoscopic hysterectomy: the Bakay technique. J Minim Invasive Gynecol. 2018;25(5):916–919. doi: 10.1016/j.jmig.2018.03.013.
    1. Srikrishna S, Robinson D, Cardozo L. Validation of the Patient Global Impression of Improvement (PGI-I) for urogenital prolapse. Int Urogynecol J. 2010;21:523–528. doi: 10.1007/s00192-009-1069-5.
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. doi: 10.1097/.
    1. Nezhat C, Nezhat F, Admon D, Nezhat AA. Proposed classification of hysterectomies involving laparoscopy. J Am Assoc Gynecol Laparosc. 1995;2(4):427–429. doi: 10.1016/S1074-3804(05)80065-9.
    1. Schulz KF, Altman DG, Moher D, Group C CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Open Med. 2010;4:e60–e68.
    1. Hefermehl LJ, Largo RA, Hermanns T, Poyet C, Sulser T. Eberli D Lateral temperature spread of monopolar, bipolar and ultrasonic instruments for robot-assisted laparoscopic surgery. BJU Int. 2014;114:245–252. doi: 10.1111/bju.12498.
    1. Nezhat C, Kennedy Burns M, Wood M, Nezhat C, Nezhat A, Nezhat F. Vaginal cuff dehiscence and evisceration: a review. Obstet Gynecol. 2018;132(4):972–985. doi: 10.1097/AOG.0000000000002852.
    1. Schimpf MO, Harvie HS, Omotosho TB, et al. Does vaginal size impact sexual activity and function? Int Urogynecol J. 2010;21:447–452. doi: 10.1007/s00192-009-1051-2.
    1. Bastu E, Yasa C, Dural O, Ozgor BY, Yilmaz G, Gungor Ugurlucan F, Buyru F, Banerjee S. Comparison of 2 methods of vaginal cuff closure at laparoscopic hysterectomy and their effect on female sexual function and vaginal length: a randomized clinical study. J Minim Invasive Gynecol. 2016;23(6):986–993. doi: 10.1016/j.jmig.2016.07.007.
    1. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191–208. doi: 10.1080/009262300278597.
    1. Lafay Pillet MC, Leonard F, Chopin N, et al. Incidence and risk factors of bladder injuries during laparoscopic hysterectomy indicated for benign uterine pathologies: a 14.5 years experience in a continuous series of 1501 procedures. Hum Reprod. 2009;24:842–849. doi: 10.1093/humrep/den467.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera